Adherence to COVID-19 preventive measures and associated factors in Ethiopia: A systematic review and meta-analysis

Background Reluctance to the COVID-19 preventive measures have been repeatedly reported in Ethiopia although compliance with these actions is the key step to minimize the pandemic’s burden. Hence, this systematic review and meta-analysis aims to address the gap in the literature by determining the pooled magnitude of adherence to COVID-19 preventive measures and identifying its associated factors in Ethiopia. Materials and methods The electronic databases used to search articles were PubMed/MEDLINE, CINAHL, Web of Science, ScienceDirect, Research4Life and other sources of grey literature including Google Scholar and World Health Organization (WHO) database portals for low- and middle-income countries. Full English-language articles published between 2019 and 2022 were eligible for the review and meta-analysis. Relevant data extracted and descriptive summaries of the studies presented in tabular form. The methodological quality of articles assessed using the Joanna Briggs Institute (JBI) quality assessment tool. The pooled magnitude of adherence determined by applying a random-effects model at a 95% CI. Results Of 1029 records identified, 15 articles were included in the systematic review and 11 were selected for meta-analysis. The pooled estimate of adherence to COVID-19 preventive measures in Ethiopia was 41.15% (95% CI:32.16–50.14%). Furthermore, perceived COVID-19 disease severity (AOR:1.77, 95% CI: (1.40–2.25)), attitude (AOR:1.85, 95% CI: (1.36–2.53)) and knowledge (AOR:2.51, 95% CI: (1.67–3.78)) to COVID-19 preventive measures showed significant association with adherence to COVID-19 preventive measures. Conclusion The magnitude of adherence to COVID-19 preventive measures in Ethiopia appeared to be low. Therefore, the government of Ethiopia and other stakeholders should mobilize resources to improve the adherence level of the community to the COVID-19 preventive measures and decrease public fatigue.


Introduction
The current pandemic, COVID-19 disease, is a highly contagious viral infection caused by novel coronavirus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Person-to-person spread is the main means of transmission, when any infected person sneeze or cough respiratory droplets of the virus, and these droplets enter the lungs of a nearby person via inhalation. Besides, environmental contamination is another way to spread the virus, resulting in an unprecedented threat to global health and well-being. Patients infected from SARS-CoV-2 infection often presented with dry cough, fever, sputum production and shortness of breath and upper airway congestion [1,2].
The WHO has recommended multiple COVID-19 prevention and control measures including proper hand washing, physical distancing, covering mouth and nose when coughing and sneezing, avoiding touching face and staying at home [3]. Several countries have implemented the WHO recommendations to prevent and control COVID-19 infection [4]. The earlier announcement of lockdown and the stricter the adherence was believed to lead to fewer infected total cases and deaths. Hence, it was expected to accelerate the containment of the virus and lessen the consequences of the mitigating measures [5]. Unfortunately, globally, as of 1 August, 2022, there were more than 577 million confirmed cases of COVID-19, including 6.4 million deaths, reported to WHO [6].
In Ethiopia, following the confirmation of the first case of COVID-19 in March 2020, the Ethiopian ministry of health and public health institute have taken several initiatives to decrease the burden of COVID-19 [7]. Among these, hand hygiene, facemask and social distancing were the primary three preventive measures that the government communicated to the community through various media platforms [8]. Furthermore, measures were imposed to close schools, restrict major gatherings and movements of people, and even lockdown. Despite this, the preventive measures were being ignored by the community and leaders at different level [9].
Poor adherence towards COVID-19 mitigation measures has continued as an escalating problem in Ethiopia [10]. According to the study conducted among Hossana residents, nearly half of them had poor adherence to the COVID-19 preventive measures [11]. Likewise, in a recent study in the capital of Ethiopia, Addis Ababa, nearly 40% of the community has shown poor implementation of COVID-19 preventive measures [12]. Surprisingly, in a study of Oromia region of Ethiopia, the overall adherence level of the community to the recommended safety measures of COVID-19 was 8.3% [13], which seems far lower than the other studies. The main barriers to effective implementation of public health measures were resistance to change, lack of community engagement, negligence, insufficient training for front line workers, poor law enforcement, poor supportive supervision, and lack of continuous community awareness creation [14].
However, there is no pooled evidence on the magnitude of adherence to COVID-19 preventive measures and its associated factors in Ethiopia. Thus, this meta-analysis aims to estimate the magnitude of adherence to COVID-19 preventive measures and its associated factors. More importantly, the systematic review and meta-analysis results will help decisionmakers to plan and implement effective action against the COVID-19 pandemic.

Search strategies
Research articles were accessed through electronic web-based database searches and reference list reviews using the Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) checklist guidelines [15]. Literature that reported adherence status to COVID-19 preventive measures and/or its associated factors in Ethiopia were searched from both main electronic databases and grey literature sources. The electronic databases used to search articles were PubMed/MEDLINE, ScienceDirect, Web of Science, CINAHL, Research4Life and other World Health Organization (WHO) database portals for low-and middle-income countries. In addition, the researchers found related articles through a desk review of the doctoral dissertations available at Ethiopian university libraries and institutional repositories, and from reviewing the reference lists of related articles. Electronic database searches were conducted from July 20, 2022, to July 23, 2022. The main terms used during electronic database search were: ("Adherence" OR "Compliance" OR "Associated factors" OR "Determinants" OR "Predictors") AND ("COVID-19 prevention measures" OR "COVID-19 preventive measures") AND (Ethiopia). Please see S1 Table for a detail article searching process, terms used in each database and search results.

Inclusion and exclusion criteria
All English-language, full-text, original research articles conducted in Ethiopia from January1, 2019 to July 23, 2022 and published in peer-reviewed journals or filed as completed dissertations were considered for inclusion. Moreover, the article should measure the adherence level and/or associated factors of COVID-19 preventive measures in Ethiopia. However, case series, opinion papers and reports were excluded.

Studies screening and selection process
All electronic search results were transferred into Mendeley reference manager software version 1. 19.8. Next, we organized all these articles into a single folder for duplicate citation removal and further management of articles. After removing duplicate citations with the software, two authors (GG, RP) independently screened the articles, based on preset eligibility criteria. The article screening process had three sequential stages, title, abstract and full-text screening. Through title screening, studies entitled with terms directly/indirectly measure the adherence level and/or associated factors of COVID-19 preventive measures in Ethiopia, were selected for abstract screening. And, in abstract screening, articles were read their abstract if they could measure either of the review and meta-analysis outcomes. Consequently, full-text screenings were carried out with four independent authors. The final decision whether to include an article were reached on the consensus of all the authors. The screening and selection of articles were guided according to the PRISMA guideline (Fig 1).

Critical appraisal of studies
Quality of studies was critically evaluated for the validity of results. The methodological quality of the papers was assessed using the JBI quality assessment checklists for cross-sectional analytical studies [16]. This JBI critical appraisal checklist has eight elements, which mainly addresses the methodological area of each article. It focused on the appropriateness of the statistical analysis, objective, inclusion criteria, study population and setting, exposure and outcomes measurement, and management of confounding factors. The evaluation and decision of each article was finalized on the consensus of all authors. Accordingly, articles with positive answers (yes) for more than 50% of the eight-elemental checklist (i.e., yes for five or more) were included in this systematic review and meta-analysis (S2 Table).

Data extraction
After all authors agreed on the articles to be included in the review and meta-analysis, we set an extraction template in the Microsoft Excel sheet. The study description in Table 1 was   Table).

Outcome of interest
The primary outcome of interest was the pooled magnitude of adherence to COVID-19 preventive measures in Ethiopia. The magnitude of adherence was measured as the number of adhering study subjects divided by the total sample size multiplied by 100. Secondly, we have also pooled the odds ratio of each factor to see if there was a statistical association with adherence to COVID-19 preventive measures in Ethiopia.

Data analysis
The raw data in the Microsoft Excel spreadsheet template was transferred to STATA™ version 16 software for analysis. A pooled magnitude of adherence to COVID-19 preventive measures in Ethiopia was estimated at a 95% confidence interval (CI). Furtherly, we conducted a regional subgroup analysis. Also, a pooled odds ratio of different variables was calculated using a RevMan version 5.4.1 to check if there was an association between independent variables and the dependent variable (adherence to COVID-19 preventive measures). The heterogeneity of study outcomes was assessed using the I 2 statistic [17]. Accordingly, studies with high heterogeneity were estimated using a random-effects model, and fixed effect model was run in variables showed low heterogeneity (<50%). Parallelly, a publication bias was checked using a funnel plot asymmetry and Egger's and Begg-Mazumdar Rank correlation tests [18]. Eventually, the statistical analysis and the results were double-checked by all authors.

Quality appraisal of the review
The JBI quality assessment tools were used to evaluate the methodological quality of the articles, based on the consensus of the two evaluators (RP, GD). We included studies with clear eligibility criteria for inclusion in the sample, a detailed description of the context, a reliable and valid measure of exposure, and adequate statistical analysis. Both authors agreed that articles with � 50% of the total score to be included in the systematic review and meta-analysis. As a result, 15 studies were of high methodological quality for the primary outcome of interest [10,11,13,[19][20][21][22][23][24][25][26][27][28][29][30] (S2 Table).

Publication bias
Publication bias was evidenced on both the funnel plots of precision asymmetry and the Egger's test of the intercept. We run a trim and fill analysis in the random-effects model [32]. The magnitude estimates did not differ significantly between the initial and, trim and fill models (Figs 2 and 3).
Sex. In this meta-analysis, the sex of the study participants was found to be a statistically significant factor in the adherence level of COVID-19 preventive measures. Male participants were 36% less likely to adhere to COVID-19 preventive measures than female participants (AOR:0.64, 95% CI: (0.54-0.78)). The heterogeneity between these studies was low (Fig 6).
Age. Also, age was another factor that had a statistically significant correlation with the adherence status of study participants to COVID-19 preventive measures in Ethiopia. People who were younger than 40 years old had 1.6 odds of adherence to COVID-19 preventive measures (AOR:1.6, 95% CI: (1.04-2.46)) (Fig 7).    Knowledge of COVID-19 preventive measures. The present meta-analysis also found that people's knowledge about COVID-19 preventive measures significantly associated with their adherence status to the COVID-19 preventive measures. Those who had good knowledge about COVID-19 were 2.51 more likely to adhere to COVID-19 preventive measures than those who had poor knowledge, (AOR:2.51, 95% CI: (1.67-3.78)) (Fig 8).
Perceived severity of COVID-19 disease. Perceived COVID-19 severity was also another significant variable that correlated with the peoples' adherence status to the COVID-19 preventive measures in Ethiopia. People who had perceived the severity of COVID-19 infection

Discussion
This systemic review and meta-analysis attempted to estimate the pooled magnitude of adherence to COVID-19 preventive measures and its associated factors in Ethiopia. We found 41.15% of the people were adhered to the COVID-19 preventive measures in Ethiopia. This is consistent with a previous review in the country where the pooled level of health professional' practice, towards WHO COVID-19 management and personal protection recommendations, estimated to be 40.3% [36]. This low level of adherence to COVID-19 preventive measures could be related with public fatigue, ignorance, misinformation, personal or social norms and perceived behavior control [37][38][39][40].
Another aim of this study was to identify the associated factors of adherence to COVID-19 preventive measures. Accordingly, sex, age, perceived COVID-19 severity, attitude, and knowledge of COVID-19 preventive measures were found to have a statistically significant association with the adherence to COVID-19 preventive measures.
Regarding sex, male participants were 36% less likely to adhere to COVID-19 preventive measures than female participants (AOR:0.64, 95% CI: (0.54-0.78)). This finding is consistent with previous studies conducted in Canada, China, Brazil, Uganda and Somalia, where male participants had had lower compliance with the COVID-19 preventive measures [41][42][43][44][45]. In the context of Ethiopia, men are the one often who runs the outdoor day-to-day activities that may lead to break the COVID-19 preventive measures.
People who were younger than 40 years old had 1.6 odds of adherence to COVID-19 preventive measures (AOR:1.6, 95% CI: (1.04-2.46)). We believe that Ethiopia has a higher educated adult population than it had before decades. Therefore, related with the recent digital technology advancements, the young generation might have better awareness and adherence to COVID-19 preventive measures than the old population. Conversely, studies from Brazil and Switzerland indicated that young adults are non-compliant [41,46]. This controversy might be because of the socio-demographic differences of study participants between Ethiopia and, Brazil and Switzerland.
In our meta-analysis, those who had good knowledge about COVID-19 preventive measures were 2.51 more likely to adhere to COVID-19 preventive measures than those who had poor knowledge, (AOR:2.51, 95% CI: (1.67-3.78)). This finding is complementary to that of the Democratic Republic of the Congo [47]. In connection, knowledge of restrictions can also predict positive attitudes towards restrictions and increase perceived ability to adhere to the mitigating measures as well [48]. Therefore, in this review, people who had a favourable attitude towards COVID-19 preventive measures had had 1.85 times more likely to adhere to the preventive measures (AOR:1.85, 95% CI: (1.36-2.53)). In line with this, a study from Iran established the positive relationship between positive attitude towards the effectiveness of preventive measures and adherence to them [49]. Therefore, the participants' awareness and attitude could have an impact on their level of compliance to the rules and regulation of COVID-19 preventive measures.
Our finding also revealed that people who perceived the severity of COVID-19 had 1.77 odds of adherence to the COVID-19 preventive measures, (AOR:1.77, 95% CI: (1.40-2.25)). In previous studies, perceived susceptibility to COVID-19 infection and perceived severity of health-related consequences were linked to engagement in disease-preventive behaviors. Consequently, there is a possibility of a positive relationship between perceived severity and adherence [50][51][52][53]. Also, according to previous Health Belief Model (HBM)-based studies, people's perception of the seriousness of having COVID-19 infection can dictate them to comply with recommended preventive measures [54][55][56][57].

Limitations
Our systematic review and meta-analysis had some limitations. First, all included studies were cross-sectional by design. Instead, it would have been more impactful if studies with variety of design had been included in the review. Secondly, the presence of heterogeneity between studies may not be supportive to draw inclusive inference about the general population.

Conclusion
This systematic review and meta-analysis found that the level of adherence to COVID-19 preventive measures in Ethiopia was low, below 50%. Furthermore, sex, age, perceived COVID-19 severity, attitude and knowledge to COVID-19 preventive measures were found to have a statistically significant association with adherence to COVID-19 preventive measures. Therefore, the government of Ethiopia and other stakeholders should mobilize resources to improve the adherence level of the community to the COVID-19 preventive measures and decrease public fatigue.
Supporting information S1